Modern Medicine and the Uncertain Body

Pergamon Soc. Sci. Med. Vol. 45, No. 7, pp. 1041-1049, 1997 i( ', 1997 Elsevier Science Ltd. All rights reserved

PII: S0277-953~97)00031-2 Printed in Great Britain 0277-9536/97 $17.00 + 0.00

MODERN MEDICINE AND THE "UNCERTAIN BODY": FROM CORPOREALITY TO HYPERREALITY?

SIMON J. WILLIAMS Department of Sociology, University of Warwick, Coventry CV4 7AL, England, U.K.

A~tract--This paper (re)considers the role of medical technology at three interrelated levels: first, the extent to which medical technology renders our bodies increasingly "uncertain" at the turn of the century; second, the analytical purchase which the notion of the (medical) cyborg provides regarding contemporary forms of human embodiment; and finally, at a broader level, the issues this raises in relation to a (late) modernist or postmodernist reading of contemporary medical practice. Key themes here include the plastic body, the bionic body, communal/interchangeable bodies, (genetically) engineered/ chosen bodies, and virtual bodies. The paper concludes with a critical appraisal of these themes and issues, arguing for a late modernist position on medical technology as both a positive and negative rationalising force, and a "life political agenda" in which the "all-too-human" quality of human nature is seen as inviolable. 1997 Elsevier Science Ltd

Key words--medicine, (late) modernity, technology, body, cyborg, plastic surgery, genetics, virtual reality, postmodernism

INTRODUCTION

As we approach the turn of the 21st Century, few would disagree with the assertion that we live in an increasingly "mediated" and "contested" age. Here, late modernist readings of contemporary social life as a reflexive order--one in which the consequences of modernity are only now becoming fully realised and the self remains a pertinent theme--vie with postmodern critiques of reason and truth, the uni- versalising claims of logocentric metanarratives, and progressive (linear) notions of history, science and technology. As a potent metaphor of society, the body too becomes a contested site upon which these broader dramas of contemporary social theory are played out. In particular, the recent upsurge of interest in body matters within the academy, the growth of social reflexivity, the postmodern attack on the disembodied Cartesian rational actor, and the proliferation of new technologies designed to control, (re)shape, and mediate our corporeal re- lations with others, have all meant that our sense of what precisely the body is and what it might become is increasingly uncertain. The body, in short, has become a "project", one which is reflex- ively open to control amidst a puzzling diversity of imperatives, choices and options. This, in turn, sets up something of a paradox, namely: the more control we have over our bodies, the less certain they become (Shilling, 1993).

Alongside the vicissitudes of the body and self- identity in consumer culture, a key issue here has been the advent of the so-called "cyborg". As Haraway (1991) argues, hypothetically and materially, the cyborg is a "hybrid" of cybernetic device

and organism; a "scientific chimera", but also a social and scientific reality in the contemporary era; a "myth and a tool", "representation and an instru- ment". More precisely, cyborgs exist when two types of boundaries are simultaneously breached: that between animals (or other organisms) and humans, and that between self-governing machines (automatons) and organisms, especially humans as models of autonomy. The "cyborg" is a "leaky" figure born of the "interface" between "automaton" and "autonomy", nature and culture, masculinity and femininity, Self and Other, rendering these divisions indeterminate and thus offering the potential to escape from their oppressive confines (Haraway, 1991).

Whilst this may sound wild and fanciful, it is clear that the "cyborg", "posthuman", or "transhuman" is not just a creature of science fiction, television or film. Rather, as Gray argues, there are already many "cyborgs" among us in society, from fighter-bomber pilots in state-of-the-art cockpits to our grandmother with a pacemaker (Gray, 1995, pp. 2-3). Given this broad range, "cyborgs" are perhaps best conceptualised on a continuum with the human organism at one end (i.e. the "all-human pole") and the pure machine (automaton) or artificial intelligence (AI) device at the other (Featherstone and Burrows, 1995, pp. 11-12).

Within all this, it is clear that developments in biomedical science, from cosmetic surgery to genetic engineering, and advancements in nanotechnology, have played a central role (Featherstone and Burrows, 1995, p. 3), leading some to contemplate that the next generation may well be the last of

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1042 Simon J. Williams

"pure" humans (Deitch, 1992). Indeed, even the "quickest tour" of the human body, from head to toes, reveals the great variety of ways in which medicine can turn humans into "cyborgs"--from restorative or normalising, to reconfiguring or enhan- cing technologies (Gray, 1995, p. 3).

At a broader level, it is also clear, in an increasingly reflexive age (Giddens, 1991), that considerable ambivalence surrounds the public perception and lay evaluation of (medical) science and technology. On the one hand, perhaps more so now than ever before, people look to medicine for a solution to their ills, from hip replacements to organ transplants. On the other hand, these (overinflated) ex- pectations, coupled with increasing awareness of the risks of iatrogenic medicine and the benefits of hol- istic therapies, mean that medicine is, at one and the same time, a fountain of hope and font of despair. These tensions and dilemmas have received an added spur with the advent of the new genetics. Here the Frankensteinian nightmare of "science gone mad", juxtaposed with media reportage of the "miracles" of the new reproductive technologies in bringing hope to previously infertile couples, makes for a heady brew of awe and scepticism at the turn of the century (Williams and Calnan, 1996a,b).

This, in turn, suggests that it is time to take stock and to (re)consider the role of medical technology at three interrelated levels. First, the extent to which medical technology renders our bodies increasingly "uncertain" at the turn of the century; second, the analytical purchase which this notion of the (medical) cyborg has in terms of contemporary forms of human embodiment in a technologically mediated age; and finally, at a broader level, the issues which this raises in relation to a late modern or postmodern reading of contempoary medical practice. As this paper shall argue, whilst postmodern interpretations of these developments are indeed possible, medicine is still in fact, first and foremost, a modernist enterprise, steeped in a scientific tradition in which truth, order and progress are seen as paramount virtues. Seen in this light, current developments in medical technology represent a further extension of modernist imperatives centred on rational control and the domination of "nature" [i.e. the "socialising of biological mechanisms" through "~internally referential" systems of social control (Giddens, 1991)]. This, in turn, raises broader issues concerning the social "costs" and "'benefits" of these new technologies, and the ethical basis upon which to judge them. Clearly these are complex issues, and they shall be returned to later in the course of the paper. For the moment, however, it is to the first main theme of the paper, namely the "re-forming" of the body in high technology medicine, that we now turn.

"RE-FORMING" THE BODY IN HIGH TECHNOLOGY MEDICINE?

As suggested above, whilst current developments in medical technology offer us unprecedented control over our bodies, they also lead to a growing crisis of identity concerning what precisely the body is and what it might become. It is here that the "leaky" (postmodern) figure of the cyborg can be seen to render previous forms of human embodiment problematic. In particular, we can see this process occurring at a number of different levels within the technological clinic or "transhuman bodyshop" of late 20th Century medicine.

Plastic bodies

First, advances in medical science and technology have meant that bodies are becoming increasingly plastic (i.e. able to be moulded at will). Technologies of cosmetic surgery, for example, have greatly expanded the limits of how the body may be restyled, reshaped and rebuilt (Davis, 1994). Amongst the rapidly growing array of technologies on offer are facelifts, rhinoplasties (nose contouring), otoplasty (ear surgery), eyelid corrections, lip enlargements, chemical peeling and dermabrasion, breasts correction (mastopexy, reduction, augmenta- tion), the stripping of varicose veins, fat removal, body contouring (liposuction or suction lipectomy) and penile enlargement. In these "body sculpting clinics" flesh is either added or taken away, wrin- kles disappear, breast become inflated or deflated, and body shape is transformed (Davis, 1994). As a consequence, notwithstanding frequent compli- cations-from scarring, bleeding, secondary infec- tions and skin discolouration to nerve damage, loss of sensation and impaired motor ability (Glassner, 1995, p. 170)--the constant (re)makeability of the human body and the power of medical technology are visually sustained in each "'exhibit" (Balsamo, 1995a,b, 1992).

As Glassner observes, within consumer culture, "professional body remakers'" function like "surro- gate psychiatrists": we literally expect them to make us into "some body new" (Glassner, 1995, p. 161). Indeed, the extension of plastic surgery into the realm of body improvement has led to a "veritable boom" in cosmetic surgery as a kind of aesthetic technological "fix" (Clarke, 1995, p. 147). For example, the number of cosmetic surgery operations performed in the U.S. doubled between 1981 and 1987. Today, some 600,000 operations are performed annually in the U.S. to make people look younger or more beautiful, with women making up the vast majority and a growing male market. Men, for example, account for a quarter of all nose jobs (rhinoplasties) and one fifth of eyelid surgery (ble- pharoplasties). Given our tendency to "'confuse beauty with health", cosmetic surgery stands a good chance of winning widespread public accep-

Modern medicine and the "uncertain body" 1043

tance over the next few decades (Glassner, 1995, pp. 168--170).

Not only does plastic surgery throw into critical relief the commodified nature of the body in consumer culture, it also indicates the extreme lengths to which individuals will go in order to mould and shape their bodies in line with people's self-identi- ties and the prevailing cultural mandates of beauty. As Glassner states:

Bodies themselves have become objects to be sold in American society. Surgeons sell not just corrections to the body.., but something far more transitory, ,fashions. They alter the size and shape or our buttocks, breasts, noses, or eyes to fit current styles... No longer can we merely dress up the body we happen to have, or improve it by losing weight or having a beauty makeover or straightening out the curve in our nose. We actually purchase a "new body" (Glassner, 1995, p. 175).

Viewed within this context, cosmetic surgery is best seen as "dilemmatic"; both a symptom and a solution, oppression and liberation all at once. Something which paradoxically enables women to feel "embodied subjects" rather than "objectified bodies" (Davis, 1994, p. 161).

The story of ~'plastic" bodies does not, however, end here. Rather, recent advances in medical technology are also now busy spinning plastic into tissue. Using biodegradable plastic seeded with cells, computer-aided "scaffolding" has been constructed to provide a template for the formation of new tissue. As the cells divide, this plastic structure is cov- ered and eventually degrades, leaving only tissue ready for implantation in the patient. This approach has already been demonstrated on animals, and during the past few years, human skin grown on polymer substrates has been grafted onto burn patients and the foot ulcers of diabetics, with some success (Langer and Vacanti, 1995). Eventually, complex body parts, such as hands and arms will be produced through these forms of tissue engineering. Indeed, the structure of these parts can already be duplicated in polymer scaffolds using computer-aided contouring, and most of the rel- evant tissue types (e.g. muscle, bone, cartilage, ten- dons, ligaments and skin) can readily grow in culture. Seen in these terms, whilst the engineering of artificial tissue and organs is a logical next step in the treatment of injury and disease, this time the "engineers will be the body's own cells" (Langer and Vacanti, 1995, p. 100).

Bionic~interchangeable bodies

Moving from its surface to its interior, the body also becomes increasingly bionic with cardiac pacemakers, valves, titanium hips, polymer blood vessels, electronic eye and ear implants and even polyurethane hearts (Synnott, 1993). Closely allied to this, bodies are also becoming increasingly communal/interchangeable through developments such

as organ donation and transplantation surgery (Synnott, 1993).

As Hogle notes, body parts are becoming increasingly "widget" like (i.e. standardised items to be replaced as needed on demand). In particular, the organisation, procurement and delivery of human organs has been transformed from an altruist patient-centred enterprise to an increasingly international "for-profit" market-based industry. As the production of human organs and tissues becomes ever more routinised, parallel processes have developed to create; '"product specific' handling, market- ing and even accounting systems" (Hogle, 1995, p. 209). Technical developments are therefore increasingly centred on "presentation" of the materials for transplant (i.e. fast acting liquids for freezing the contents of the entire peritoneal cavity). Whilst previously the term "presentation" referred to the sto- rage of materials after explantation and during transplant to the end user:

Now...presentation begins much earlier; within the body itself. Recognising the considerable market potential of the human materials industry, pharmaceutical and medical supply companies have developed new products and entire new industries designed specifically for use in donor cadavers. These include free-oxygen scavengers, "hibernation hormones", new perfusion and preservation fluids, and other chemicals to preserve tissue integrity before being removed, and to make the materials more "immunologi- cally silent" to prevent problems later when they are replaced inside another body. In essence, the human materials are being structurally, chemically and functionally transformed to make them more universal. In this way, they become not only substitutable mechanical parts, but more like off-the-shelf reagents, available for use in a variety of end-users (Hogle, 1995, p. 208).

Through these "core technologies", cadavers are being transformed into what Hogle terms "donor cyborgs" as the physical body is "reprogrammed" and "retooled" for new uses. When the donor cyborg reaches its almost-total-technology state its parts are dispersed and distributed throughout the "communal body" to innumerable others. In this way, transplanted human body parts become the "seeds" that reproduce and replicate other new "cyborgs" (Hogle, 1995, p. 207).

Not only are bodily organs interchangeable at the human to human level, they also now cross species boundaries, as in xenotransplantation--the use of animal organs for transplant surgery. To be sure this raises a number of ethical dilemmas, issues made all the more pressing with the announcement in late 1995 of a new development enabling scientists to produce a customised pig whose organs would be less likely to induce fatal rejection in the human recipient. The company involved, Imutran, reported the creation of "Astrid", the first of these pigs, which was duly given much media attention. Such developments, along with the creation of other "transgenic" animals (i.e. animals carrying genes from another species), and the use of animals in tissue engineering (i.e. the "mouse with the


human ear') - -another issue given considerable media coverage in early 1996--pose many moral, social and cultural questions about individual and species bodies, and the constitution of the "natural".

In particular, this again raises, in acute form, thorny questions about the meaning(s) of corporeality, self identity and the nature of death. If the pig, for example, is seen as a ritually "unclean" animal, one involving "matter out of place" and the "transgression" of cultural boundaries (Douglas, 1966), then how do we see ourselves with an animal heart inside us, and how does this square with, say, orthodox Jewish beliefs, or those of a vegetarian or anti-vivisectionist? Does the body become degraded, defiled or debased in some way as a consequence, and if so, what implications does this "grotesque" body have for our sense of who and what we are?

As Joralemon (1995) argues, transplantation chal- lenges traditional views of body/self integrity by dis- tinguishing between the brain and other, more replaceable, body parts which, in turn, simultaneously reinforces a traditional Cartesian split between body and mind. Organ transplantation thus poses many questions about self-identity. Cultural beliefs about selfhood may, moreover, conflict with medical images of body parts. Sharp's (Sharp, 1995) study of how patients undergo some degree of restructuring of their sense of self after transplant surgery stresses the disjunction between the need to personalise and the need to objectify bodies and organs. Medical personnel put great stress on objectification; the heart, for example, is "only a pump". Yet recipients experience conflict between this mechanistic/reductioinist view of the body and their wider cultural beliefs about the embodied nature of self identity and the "sacred" nature of the heart as the very core of the person.

As suggested earlier, one of the greatest problems with transplant surgery has been the issue of "rejection". Certainly, immunology can be seen as an important "barrier" which is "limiting" many of these technologies at present, and it is in this area that advances can be expected over the next few decades--a development which, in turn, links up with the advent of "psychoneuroimmunology" as a new model within medical science and technology (Levin and Solomon, 1990). More generally, as Langer and Vacanti (1995) suggest, medical science, over the next few decades, will move beyond the practice of transplantation surgery altogether and into the era of fabrication; the ultimate goal being to manufac- ture organs rather than simply move them, and to produce, through genetic engineering, universal donor cells (i.e. cells that do not provoke rejection by the immune system) for use in these engineered tissues. Here we return to the previous theme of "plastic" bodies (i.e. the "spinning of plastic into tissue" and the "mouse with the human ear"). In addition, we also anticipate the next issue of geneti-

cally engineered bodies and the prospect of "designer" babies.

Geneticafly engineered bodies/"designer" babies

As suggested above, developments in modern medical technology mean that the body becomes increasingly engineered through new forms of gene therapy, and even chosen or selected from a growing number of ovum and sperm banks (Synnott, 1993, pp. 34-35). As Anderson (1995) notes, over the course of medical history there have been three great leaps in our ability to treat and prevent disease. First, the implementation of public health measures; second, the introduction of surgery with anaesthesia; and third, the use of vaccines and anti- biotics. Gene therapy, at the turn of the 21st Century, represents the "fourth great leap". Whilst todays understanding of the precise genetic bases for many diseases is sketchy, knowledge will increase enormously in the next few decades. By the year 2000, for example, scientists working on the Human Genome project should have determined the chromosomal location of, and deciphered parts of the DNA code in, more than 99% of active human genes. Similarly, research aimed at uncover- ing the function of each gene is progressing rapidly. Such information should make it possible to ident- ify the genes which malfunction in various diseases (Anderson, 1995, pp. 97-98).

These issues, in turn, suggest a veritable cornuco- pia of ethical qualms and moral dilemmas. Will developments in screening technologies, for instance, lead to recruitment policies involving rig- orous genetic testing for "markers" of future disease before acceptance onto the company books? Would this be legally admissible, and if so, what are our chances of finding employment in a future "'genetically discriminatory" labour market? Taking this argument one step further, would these "'defects" be screened out before birth, and if so, where exactly would the process end?

For the next decade, gene therapy is most likely to be confined to somatic cells (i.e. all cell types except sperm, eggs and their precursors). Alteration of these cells only affects the patient undergoing treatment, as opposed to reproductive, or germ cells, which would affect all descendants of the original patient. Existing approaches to somatic cell gene therapy include several different techniques, including ex vivo ("outside the living body") therapy, and in situ ("in position") therapy, cur- rently used for the treatment of cystic fibrosis. A third form of treatment is hi vivo ("in the living body") therapy (Anderson, 1995). Although still at the experimental stage, this constitutes a promising line of future development in gene therapy. Here physicians will simply inject corrective gene carriers into the bloodstream of the patient in much the same way as many drugs are administered now (Anderson, 1995, pp. 98--98B).


These forms of gene therapy, in turn, key into broader debates concerning the new reproductive technologies. As Clarke (1995) argues, in contrast to "modern" approaches to reproduction--techniques which centred on achieving and/or enhan- cing control over bodies and reproductive processes for a variety of purposes via monitoring, planning, limiting, bounding and the setting up of boundaries--postmodern strategies, centred around these so-called new reproductive technologies, concentrate instead upon the "re/design" and transformation of reproductive bodies and processes to achieve a variety of goals.

On the one hand, as Stanworth notes (Stanworth, 1987, p. 1), these new technologies--from artificial insemination to gamete intra-fallopian transfer (GIFT) and a host of hormonal and other infertility treatments--appear to offer a range of possibilities for extending the pleasures of parenthood to those who, for whatever reasons, have hitherto been unable to have a child. Not only do they offer the chance for potential parents to know, before birth, about any genetic or chromosomal "abnormalities", they also hold out the promise of the eventual elim- ination of some of these defects before conception takes place. In addition, of course, they more or less completely sever reproduction from the traditional categories of heterosexual experience-- what Giddens refers to as "plastic" sexuality in the late modern age (Giddens, 1991, 1992). Future developments here include the transplantation of donated precursors of sperm cells into the semini- ferous tubules of the testes of infertile men, whilst in the field of contraceptives, vaccines (immunocon- traceptives) able to disrupt sperm function are cur- rently being developed for men and women (Alexander, 1995).

On the other hand, however, these new technologies extend the boundaries and possibilities of medical and scientific practice in ways which threaten to outstrip human understanding, public moral- ity and control. Not only do they bring new dangers and unknown risk to parents and children alike who undergo them, they also allow greater scope for the application of eugenic policies which place a higher value on some lives rather than others, interfere with the "naturalness" of reproduction, and threaten to turn babies into "commod- ities" which can be bought and sold. In this respect, as Stanworth (1987) notes, the "Frankensteinian nightmare" of "science gone mad" is readily con- jured up in the public mind as scientists start manipulating the very foundations of life itself, as well as potential problems across the life course (p. 2).

As this suggests, these new technologies open up to debate issues which formerly belonged to the realm of biological "givens". This in turn facilitates the emergence of "life political" agenda in which existential, moral and legal issues concerning the

ownership and control of the human body come to the fore (Giddens, 1991, 1994). Key questions here include the ethical and practical problems surrounding the manipulation of eggs, sperm and embryos outside the human body, the problems of "parenthood", especially "motherhood", and the "threats" to identity which these technologies pose for the human "products" they create (Stanworth, 1987). Should these new reproductive techniques be used "eugenically", for example, in order to produce "brighter", more "attractive", or more "artistic" offspring, and should (donor) children have a right, when reaching maturity, to know who their "real" genetic parents are? These, and many other dilemmas are thrown into critical relief as a consequence of the "socialising of biological mechanisms" (Giddens, 1991).

In short, what is potentially being transformed through these new technologies is our conceptualis- ation of what it is to be human, male, female, reproductive, parent, child, foetus, family, "race" and even population (Clarke, 1995, p. 149). All must now be put in brackets and renegotiated as a consequence of these technological developments. Slowly but surely, humans run the risk of being reduced to their ("faulty") DNA codes and genetic "spelling mistakes". The upshot of this is that human subjectivity becomes transformed into an "object" or "collision site" for various types of detectable and usable information, whilst medicine oscillates precariously between a new concern with "codes" (e.g. immunology and genetics) and a traditional preoccupation with "combat" (i.e. disease) (Montgomery, 1991; Haraway, 1991; Martin, 1994).

Certainly these issues have been hotly debated in feminists circles. For some, the creation of NRTs is seen as the endstage of men's desire to control women and appropriate reproductive power (Corea, 1985; Corea et al., 1985; Rowland, 1992, 1985). Viewed from this perspective, the danger lurks that biological mothers will eventually be reduced to "mother machines" (Corea, 1985) or "living laboratories" (Rowland, 1985), eroding still further women's bodily and metaphysical privacy. Physiologically, women's bodies are "opened, scru- tinised, manipulated, parts extracted and then rein- troduced". This enables practitioners to unselfconsciously "speak of disembodied parts of women--'the ovaries', 'ripe eggs', and ~recovering' these parts even as they materially, scrutinise, alter or remove these parts of women's bodies" (Steinberg, 1990, p. 86, original emphasis).

As Casper (1995) argues, a host of contemporary technologies in both science and medicine have made possible the emergence of what she terms "foetal cyborgs" and "techno" mothers. These include foetal visualisation technologies; foetal diagnostic technologies; technologies which enable a foetus to live inside a braindead woman's body; technologies which transform aborted foetuses into


"materials" for scientific research and new forms of biomedical therapy; technologies which produce physiological knowledge about foetuses, and finally; an array of foetal treatment technologies including "foetal surgery" (Casper, 1995, pp. 186 187). As a consequence, women not only become "erased" but also alienated and depersonalised in the process of reproduction.

Others, however, have argued that it is not so much the technologies themselves which are problematic, but the context in which they are developed and applied, including the thorny issue of access (i.e. who is allowed to conceive). The call for a return to so-called "natural motherhood" is therefore resisted, and it is argued instead that women must themselves participate in both the development and (re)evaluation of these technologies, rather than leaving them in the hands of "male- stream" (biomedical) science (Stanworth, 1987; McNeil et al., 1990). Indeed, as Denny (1996) has convincingly shown, contra radical feminist argu- ments, many women undergoing these forms of treatment view them positively as a "resource" rather than a mechanism of "control" or "oppression".

More broadly, poststructuralist feminists have also rejected the notion that the "'real female body" is passively "'acted upon", instead preferring to view it as being both inscribed and constituted through (re)productive discursive practices and processes. From this perspective these new reproductive technologies are themselves viewed as producing subjectivity rather than "false consciousness" (Lupton, 1994). Consequently, there is a focus on the struggles and resistances between men and women and the shifting configurations of knowledge/power which this involves (Sawicki, 1991). Here the ultimate goal is to produce a feminist body/politics which allows women to speak about their bodies in their own chosen ways and thereby to resist dominant scientific and technological dis- courses (Jacobus et al., 1990). This issue of resist- ance, in turn, resonates with a more general postmodernist commitment to difference, generosity and an endless process of "becoming" within all walks of life, including the health care arena (Fox, 1993).

Virtual bodies

No discussion of medical technology would be complete without consideration of new developments in minimally invasive surgery and "virtual" medicine. Whilst many of these technologies are still in their infancy/at the prototype stage, they nonetheless promise a radical transformation of existing surgical procedures. Keyhole surgery, for example, despite recent concerns over the standard- isation of training and competence, is already well established. As Wickham (1994) speculates, reduced trauma from minimally invasive surgery will result

in fewer operations requiring lengthy hospital stays. As a consequence, traditional surgical wards will become largely redundant, hospitals will need to cope with increased patient throughput, operating theatres will have to be re-equipped with these new technologies, and hospital staff will need to be retrained in order to manage it. Many traditional specialities will also merge, and much conventional nursing care will shift to the community rather than the hospital.

In addition to these "cutting edge" technologies, including microengineering and nanotechnology, developments such as graphic workstation compu- ters and specialised tracking devices have made it possible to build an advanced prototype simulator for minimally invasive surgery called the "virtual clinic" (McGovern, 1994; McGovern and McGovern, 1994). As McGovern explains, the system uses tracking devices attached to actual surgical instruments which are inserted into a fibreglass body mould. Graphic representations of the body change as the instruments are moved, whilst inter- action is visibly displayed on a high resolution computer monitor located at the head of the "virtual" patient. Data produced by computer tomography (CT) and magnetic resonance imaging (MRI) are used to supply a visual re-presentation of the actual patient's anatomy. Computer manipulation allows the "virtual surgical instruments" to interact with the "virtual tissues" in a way that resembles what happens in "real life", with new images automati- cally created as these "virtual" tissues are dissected (McGovern, 1994, p. 1054).

The benefits of these computerised training systems include the ability to reproduce surgical anomalies, work out the best operative procedures, improve surgical techniques and thereby minimise errors on actual patients. In neurosurgery, for example, researchers are trying to combine live video information with three-dimensional computer images of the brain in order to help in the planning of operations. These methods help surgeons plan the best site for a skin incision, craniotomy, and a brain incision, thus minimising the risk of damage to normal brain tissue (McGovern, 1994).

Another interesting development here is "tele-pre- sence'" surgery, performed on a patient in an operating theatre containing a stereoscopic camera and a robot. At a separate location the surgical control workstation has a three-dimensional monitor with surgical input output devices which closely re- semble actual instruments that would be used in an operation (McGovern, 1994). On the one hand, the advantage of this system, which has been developed for use in battlefields, is that it allows surgeons to operate on patients at a distance. On the other hand, however, the issue of what happens to actual patients when things go wrong and communication lines break down, render these "virtual" forms of surgery at present highly problematic.


More broadly, as Frank (1992) observes, a pano- ply of "screens" now pervade the modern technological hospital. First, there are those screens which, as discussed earlier, exteriorise direct images of the body's interior (e.g. ultrasound screens/foetal visualisation and diagnostic technologies); second, there are screens which display online digital images, coded into graphs and pictorial display, of bodily processes and functioning (e.g. ECG monitors); third, there are screens which display symbolic images such as patient charts, schedules and other secondary data; and finally, there are commercial television screens found in ever increasing numbers in hospital waiting rooms, lounges, wards and patient rooms. In this respect, the Foucauldian clinical gaze gives way to the Baudrillardian "hyperreality of images without grounding". The upshot of this is that bodies become ever more elusive: instead of the patient's body being at the centre of contemporary medical practice and discourse, we find instead "multiple images and cod- ings" whereby the body is endlessly "doubled and redoubled" through a self-referential chain of simu- lacra (Frank, 1992, p. 83). According to this scen- ario, a modernist concern with corporeality is slowly but surely giving way to a postmodernist concern with hyperreality. This, in turn, leads us into a broader set of theoretical debates on the nature of medicine at the turn of the century: issues which shall be discussed in the concluding part of this paper.

DISCUSSION AND CONCLUDING REMARKS

At the beginning of this paper three main questions were posed. First, what role has medical technology played in the crisis of meaning surrounding the human body at the turn of the 21st Century? More specifically, to what extent has increasing technological control exacerbated our sense of uncertainty over what precisely bodies are and what they might become? To be sure, the evidence presented here would seem to suggest that advances in biomedical science and technology have been central to this moral, spiritual and existential crisis. From plastic surgery to virtual medicine, our previously held and cherished beliefs about the body and the "limits" of corporeality are being "placed in brackets", so to speak. In this sense, medical "advances" in science and technology are both instrumental in, and symptomatic of, this corporeal crisis of meaning in late 20th Century Western society; developing and extending the "rationalis- ation" of the body in important new ways, but in doing so, rending it ever more elusive and problematic. Seen in these terms, the "certainties" of rationality create their own doubts.

Second, what analytical purchase does the cyborg give us on these contemporary forms of technological embodiment? Certainly, the thrust of the argu-

ments presented in this paper would seem to suggest that, in an era where human-machine coup- lings are almost infinite, medical technology has at its disposal a variety of means to transform us into cyborgs, from cardiac pacemakers to genetic engineering, and from the nebulised asthmatic to the accident victim in the intensive care unit. The logic of this argument suggests that, in a technological age such as ours, we are all "cyborgs" in some shape, sense or form. In making this claim, however, the analytical potential and discriminatory power of the concept is surely reduced. In this respect, as has been suggested here, it is perhaps more fruitful to conceptualise cyborgs along a continuum ranging from the all-too-human pole at one end to artificial intelligence (AI) devices at the other, with a broad range of human/machine coup- lings of varying degrees in between. In contrast to Haraway's (Haraway, 1991) optimistic stance toward the cyborg as a "leaky" figure in a "post- gender" world, it is also possible to argue that the advent of these technological developments uphold rather than transcend the gendered forms of embodiment they seeks to unravel (Springer, 1991: Foster, 1993; Cherniavsky, 1993). This, in turn, reinforces the more general point that rather than challenging traditional mind/body divisions, contemporary forms of medical practice actually ex- acerbate them through a high tech form of neo- Platonism: plus ca change, plus c'est la plus la meme chose!

This leads me to the third main issue I wish to explore in this concluding part of the paper, namely whether modernist or postmodernist interpretations of these technological developments are most appropriate. Certainly, much of what I have had to say about these new technologies, from genetic engineering to virtual medicine, lends itself, potentially at least, to a postmodern reading; one in which a more direct concern with human corporeality is slowly giving way to a "digitally mediated" concern with hyperreality and the growing imbrication of humans and machines (i.e. cyborgology). Yet, in the face of this possible postmodern reading, I wish to stress an alternative interpretation, namely, that medicine continues to be a thoroughly modernist enterprise, and that these technological developments enhance rather than diminish the rational control of bodies and selves in an increasingly reflexive age. Indeed, as suggested earlier, it is these very trends of rational control which, paradoxically, create the crisis of meaning and uncertain status of the body in late modernity. Modernity, in other words, as a reflexive social order, "manufactures" its own (i.e. internally referential) risks and uncer- tainties. Medicine, as arch-modernity personified, reflects and reinforces these dilemmas in acute corporeal form. Perhaps on a more rhetorical note, it is also possible to argue that postmodernism is really only an option for the "healthy" rather than


the sick. As Charlton (1993) argues, when the "chips are down", when illness renders our contin- gent relationship to our bodies problematic, then modernist medicine offers us a candle of hope flick- ering precariously in the wind of our malaise. Modern medicine, in short, despite its limitations and iatrogenic consequences, is both a fountain of hope and font of despair. This, in turn, suggests that lay voices should be the final arbiters in these broader theoretical debates concerning the role of medical technology as liberation or oppression, opportunity or constraint (Williams and Calnan, 1996a).

This raises a fourth and final set of issues to do with the social costs and benefits of medical technology and the ethical dilemmas it poses. Certainly, as we have seen, a number of problems arise from the application of these "cutting edge" technologies, from the physical and psychological risks of cosmetic surgery, to the spectre of eugenics and the prospect of "designer babies". Nonetheless, it would wrong to "write them off" simply on these grounds. Rather, we should also acknowledge the significant contribution which medical technology has made to our lives, from improvements in the quality of life (e.g. hip replacements, cataract removal, coronary bypass surgery) to the creation (e.g. new reproductive technologies) and pro- longation (e.g. organ transplants) of life itself. Indeed, even in controversial areas such as gene therapy, certain forms of treatment would seem to be a moral obligation rather than an option (Caplan, 1995). Clearly, however, the ethical basis upon which to judge these technologies is a complex issue which extends well beyond the scope of the present paper. It is, however, possible to argue that any such of notion of ethics must ultimately concern itself with a "life political agenda" which is grounded in our embodied being-in-the-world and the inviolability of human nature. In this respect, whilst we have all been put on the "conveyor belt of biotechnology", the question we must continu- ally ask ourselves is whether our humanity is being "'compromised" in the process? (O'Neill, 1985; Scheper-Hughes and Lock, 1987). The rational, technological imperatives of late modern medicine also need to be tempered by a more "humanist" vision of health care: one which is sensitively oriented to the ill through an approach which treats human feelings and emotions as central rather than peripheral to the healing process. This, in turn, resonates with a broader postmodern ethics of care based on generosity, trust and a spontaneous commitment to the "other" vis-a-vis (modernist) posses- sive, repetitive, negative forms of dependency which discipline, smother and envelop the individual (Fox, 1993). Whatever the outcome of these broader debates, one thing remains clear: if (medical) technology symbolically expresses the dilemmas of life in an increasingly uncertain age, then the body pro-

vides the metaphor of metaphors so to speak, as both stability and flux, order and transgression. Corporeality or hyperreality, only time will tell!

Acknowledgements--I am grateful to the two reviewers for helpful comments on an earlier draft of this paper and to Lynda Birke for useful discussion of these themes.

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